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<meta name="description" content="之前拔牙有时候需要缝合，往往是跟着感觉来，甚至有时候还“自创”一些缝合方法。今天看了口外的书，总结了一下。缝合外科手术创口是必要的，其目的是使皮瓣覆盖创面，恢复（reapproximating）创面边缘，保护其下面的组织，阻止其感染或被其它因素刺激，预防术后出血。缝合的作用：①当深部组织出现出现需要进行血管结扎的时候。②对牙龈软组织撕裂的情况。③当出血比较多的时候，缝线将止血物（hemostati">
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<meta property="og:description" content="之前拔牙有时候需要缝合，往往是跟着感觉来，甚至有时候还“自创”一些缝合方法。今天看了口外的书，总结了一下。缝合外科手术创口是必要的，其目的是使皮瓣覆盖创面，恢复（reapproximating）创面边缘，保护其下面的组织，阻止其感染或被其它因素刺激，预防术后出血。缝合的作用：①当深部组织出现出现需要进行血管结扎的时候。②对牙龈软组织撕裂的情况。③当出血比较多的时候，缝线将止血物（hemostati">
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        <p>之前拔牙有时候需要缝合，往往是跟着感觉来，甚至有时候还“自创”一些缝合方法。今天看了口外的书，总结了一下。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0007-kwcyfhff/01.jpg"><br>缝合外科手术创口是必要的，其目的是使皮瓣覆盖创面，恢复（reapproximating）创面边缘，保护其下面的组织，阻止其感染或被其它因素刺激，预防术后出血。<br>缝合的作用：①当深部组织出现出现需要进行血管结扎的时候。②对牙龈软组织撕裂的情况。③当出血比较多的时候，缝线将止血物（hemostatic plug）保留在原位。④对于有感染的情况，用缝线将引流条固定在切口处。⑤将带蒂瓣固定在它们的新位置上。<br>缝线靠打结来固定，可以使简单的结或者外科结，可以用双手打结也可以持器械打结。<br>打结的技术：在针穿过创口边缘的两边以后，将缝线拉出，使缝针一端的线比较长。之后，比较长的一端的线绕持针器两圈。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0007-kwcyfhff/02.jpg"><br>较短的一端的缝线（通常用组织钳来帮助持夹）用持针器夹住，并穿过之前的两圈缝线。接着将缝线沿着它们的方向拉紧（注意是沿着原来线的方向，实操的时候我的方向经常是反的），这就是双圈结（double-wrapped knot），也叫外科结。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0007-kwcyfhff/03.jpg"><br>之后瓣就到了我们想让它到的位置。接着再打一个单圈的结，要逆时针方向打，这叫做安全结（safety knot）。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0007-kwcyfhff/04.jpg"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0007-kwcyfhff/05.jpg"><br>打的结必须在切口的旁边而不是在切口之上。这样拉紧就更容易，更少的干扰创口，也使拆线更加容易。（我打完外科结以后打安全结的时候，外科结常常会松动，离开粘膜表面，会不会就是这个原因？）<br>缝合技术：主要的缝合技术有三种，间断缝合（Interrupted Suture)，连续缝合（Continuous Suture）和褥式缝合（Mattress Sutures）。<br>间断缝合<br>是最简单而且最常用的一种缝合方式。可以被用于所有口腔外科手术当中。进针点距离瓣（可活动的组织）的边缘2-3mm，在缝线的两边是同一个方向（一边是外进内出，另一边是内进外出）。然后打结，并在结之上0.8cm（8mm）处剪短缝线。为了避免瓣的撕裂，缝针一次只能穿过一侧的组织，并且必须距离边缘至少0.5cm（5mm，看下面的图，结合上下文，应该指的是两个结之间的距离至少5mm。）。打结过紧是必须避免的（有组织坏死的风险）。在打结的时候也不能使创面边缘重叠在一起。<br>优点：当缝线排成一行的时候，一个结的松弛或者松脱不会影响其它的结。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0007-kwcyfhff/06.jpg"><br>连续缝合<br>常用来缝合较表浅但是比较长的创面，比如牙槽嵴修整术。在针穿过两边的瓣以后，打一个外科结，然后只有缝线的游离端被剪掉。接着使用缝针在创口边缘进行连续缝合（这段看不懂，在网上找了视频，打完结以后，从对侧的外面进针，内面出针，再到另一侧的内面，然后从外侧出针，如此持续）。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0007-kwcyfhff/07.jpg"><br>最后一针的时候，不要把线拉紧，用于打结。缝针绕持针器两圈，抓住没拉紧的那端缝线，使其穿过圈，两端拉紧，打结完成。（看视频，也就是把最后那个圈当成一根线，按外科结的方法打结）。<br>连续锁边缝合（continuous locking suture）是简单连续缝合的一个变异。基本方法与连续缝合一样，只是在每一次最后出针以后，缝针从未拉紧的缝线形成的圈里面穿过去，然后再到对侧进针。这个圈位置在创面的颊侧。（看视频，能使缝线更加稳固，适合于口腔粘膜的缝合。）<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0007-kwcyfhff/08.jpg"><br>优点：更快，需要的结数更少。因此创面边缘不会被牵拉过度，避免了该区域局部缺血的风险。<br>唯一的缺点：如果封线有一处松脱或者被剪断，整个缝线会松脱。<br>褥式缝合<br>有水平褥式缝合及垂直褥式缝合。当需要牢固的安全的创面边缘对合的时候使用。垂直褥式缝合用于深的切口，水平褥式缝合用于需要限制或者关闭暴露的骨腔的时候，例如，拔牙创的关闭。增强褥式缝合（Reinforcement of the mattress suture）用于插入橡皮引流条的时候。<br>技术：在间断缝合（水平或垂直的）的时候，缝针垂直于创面边缘进针，缝针始终进出于组织的同一侧，然后再从另一侧进出。在水平连续缝合中，在打了第一个结以后，针以弯曲的方式(winding maze pattern）进入并穿出组织。最后一个结用和连续缝合一样的方式来打。<br>水平间断褥式缝合<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0007-kwcyfhff/09.jpg"><br>水平连续褥式缝合：用于创面边缘必须牢固结合(coapt tightly，即增加组织张力)的情况。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0007-kwcyfhff/10.jpg"><br>垂直褥式缝合：用于较深的切口。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0007-kwcyfhff/11.jpg"><br>（视频总结：间断褥式缝合，按间断缝合进针，完了以后不要打结，而是反回去反向再进一次针，然后在一开始进针的那侧打结。创缘有外翻，力量比较大，用于容易内卷，张力比较大的伤口的缝合。垂直褥式缝合，用的不多。）<br><a target="_blank" rel="noopener" href="http://v.youku.com/v_show/id_XOTE2Njc4MjYw.html?sharekey=35a478be9348bcccb51da16a8144606d6">视频地址</a></p>
<p>我发文章的三个地方，欢迎大家在朋友圈等地方分享，欢迎点“在看”。<br>我的个人博客地址：<a href="https://zwdnet.github.io/">https://zwdnet.github.io</a><br>我的知乎文章地址： <a target="_blank" rel="noopener" href="https://www.zhihu.com/people/zhao-you-min/posts">https://www.zhihu.com/people/zhao-you-min/posts</a><br>我的微信个人订阅号：赵瑜敏的口腔医学学习园地<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/other/wx.jpg"></p>

      
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